ANKLE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE …

Updated on July 20, 2020 ~v20_2Released January 2022 of 13Ankle Conditions Disability Benefits Questionnaire

ANKLE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE

Claimant/Veteran's Social Security Number:Name of Claimant/Veteran: Date of Examination:

Note - The Veteran is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran's claim. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of the veteran's application. VA reserves the right to confirm the authenticity of ALL Questionnaires completed by providers. It is intended that this questionnaire will be completed by the Veteran's provider.

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM.

Are you completing this Disability Benefits Questionnaire at the request of:

Veteran/Claimant

Other, please describe:

Was the Veteran examined in person?

Is the Veteran regularly seen as a patient in your clinic?

Are you a VA Healthcare provider?

If no, how was the examination conducted?

No records were reviewed

Records reviewed

Evidence reviewed:

EVIDENCE REVIEW

Please identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.

Yes No

Yes No

Yes No


1B. Select diagnoses associated with the claimed condition(s) (check all that apply):

Side affected:

BothRight Left

LeftRight Both

BothRight Left

BothRight Left

LeftRight Both

BothRight Left

LeftRight Both

BothRight Left

LeftRight Both

BothRight Left

Date of diagnosis:ICD Code:

The Veteran does not have a current diagnosis associated with any claimed condition listed above. (Explain your findings and reasons in comments section.)

Achilles' tendon rupture

Retrocalcaneal bursitis

Tendonitis (Achilles/peroneal/ posterior tibial)

Impingement (anterior/posterior (or trigonum syndrome)/anterolateral)

Osteochondritis dissecans to include osteochondral fracture

Deltoid ligament sprain (chronic/recurrent)

Lateral collateral ligament sprain (chronic/recurrent)

Ankylosis of ankle, subtalar or tarsal joint

Ankle joint replacement

Avascular necrosis, talus

BothLeftRightOsteitis deformans

BothLeftRightGout

BothLeftRightBursitis

BothLeftRightMyositis

BothLeftRightHeterotopic ossification

BothLeftRightTendinopathy (select one if known)

BothLeftRightOsteoporosis, residuals of

BothLeftRightOsteomalacia, residuals of

BothLeftRightBones, neoplasm, benign

BothLeftRightDegenerative arthritis, other than post- traumatic

BothLeftRightArthritis, pneumococcic

BothLeftRightArthritis, streptococcic

BothLeftRightArthritis, syphilitic

BothLeftRightArthritis, rheumatoid (multi-joints)

BothLeftRightArthritis, post-traumatic

BothLeftRightArthritis, typhoidOther specified forms of arthropathy (excluding gout):

BothLeftRight

SECTION I - DIAGNOSIS

1A. List the claimed condition(s) that pertain to this questionnaire:

Note: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the remarks section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis or an approximate date determined through record review or reported history.

Right: Left:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:

Left:Right:BothLeftRightArthritis, gonorrheal

LeftRight BothMedial tibial stress syndrome (MTSS), or shin splints

Left:Right:

BothLeftRightBones, neoplasm, malignant, primary or secondary

Left:Right:

BothLeftRightTendinitis

BothLeftRightTendinosis

BothLeftRightTenosynovitis

Left:Right:

Left:Right:

Left:Right:


Other (specify):

LeftRight Both

BothRight Left

ICD Code: Date of diagnosis:

LeftRight Both

Side affected:

Other diagnosis #3:

Other diagnosis #2:

Other diagnosis #1:

1C. If there are additional diagnoses that pertain to ankle conditions, list using above format:

SECTION II - MEDICAL HISTORY

2A. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary):

2B. Does the Veteran report flare-ups of the ankle?

2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time?

If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment he/she experiences during a flare-up of symptoms:

If yes, document the Veteran's description of functional loss or functional impairment in his/her own words:

No

Yes No

Yes

Right: Left:

Left:Right:

Left:Right:

SECTION I - DIAGNOSIS (continued)

2D. Does the Veteran report or have a history of instability of the ankle?

If yes, document the Veteran's description of instability in his/her own words:

Yes No


3A. Initial ROM measurements

SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION

If ROM is outside of "normal" range, but is normal for the Veteran (for reasons other than an ankle condition, such as age, body habitus, neurologic disease), please describe:

Unable to test Not indicated

If abnormal, does the range of motion itself contribute to a functional loss?

NoYes

If yes, please explain:

There are several separate parameters requested for describing function of a joint. The question "Does this ROM contribute to a functional loss?" asks if there is a functional loss that can be ascribed to any documented loss of range of motion; and, unlike later questions, does not take into account the numerous other factors to be considered. Subsequent questions take into account additional factors such as pain, fatigue, weakness, lack of endurance, or incoordination. If there is pain noted on examination, it is important to understand whether or not that pain itself contributes to functional loss. Ideally, a claimant would be seen immediately after repetitive use over time or during a flare-up; however, this is not always feasible. Information regarding joint function on repetitive use is broken up into two subsets. The first subset is based on observed repetitive use, and the second is based on functional loss associated with repeated use over time. The observed repetitive use section initially asks for objective findings after three or more repetitions of range of motion testing. The second subset provides a more global picture of functional loss associated with repetitive use over time. The latter takes into account medical probability of additional functional loss as a global view. This takes into account not only the objective findings noted on the examination, but also the subjective history provided by the claimant, as well as review of the available medical evidence. Optimally, a description of any additional loss of function should be provided - such as what the degrees of range of motion would be opined to look like after repetitive use over time. However, when this is not feasible, an "as clear as possible" description of that loss should be provided. This same information (minus the three repetitions) is asked to be provided with regards to flare-ups.

RIGHT ANKLE

If "Unable to test" or "Not indicated", please explain:

All Normal Abnormal or outside of normal range

Note: For any joint condition, examiners should address pain on both passive and active motion, and on both weight-bearing and nonweight-bearing. Examiners should also test the contralateral joint (unless medically contraindicated). If testing cannot be performed or is medically contraindicated (such as it may cause the Veteran severe pain or the risk of further injury), an explanation must be given below. Please note any characteristics of pain observed on examination (such as facial expression or wincing on pressure or manipulation).

3A. Initial ROM measurements

If ROM is outside of "normal" range, but is normal for the Veteran (for reasons other than an ankle condition, such as age, body habitus, neurologic disease), please describe:

Unable to test Not indicated

If abnormal, does the range of motion itself contribute to a functional loss?

NoYes

If yes, please explain:

LEFT ANKLE

If "Unable to test" or "Not indicated", please explain:

All Normal Abnormal or outside of normal range

Can testing be performed?

NoYes

If no, provide an explanation:

Can testing be performed?

NoYes

If no, provide an explanation:

Dorsiflexion endpoint (20 degrees):

Plantar flexion endpoint (45 degrees): degrees

degrees

Active Range of Motion (ROM) - Perform active range of motion and provide the ROM values.

Active Range of Motion (ROM) - Perform active range of motion and provide the ROM values.



degrees

If this is the unclaimed joint, is it: UndamagedDamaged If this is the unclaimed joint, is it: UndamagedDamaged

If undamaged, range of motion testing must be conducted. If undamaged, range of motion testing must be conducted.


Plantar flexion degree endpoint (if different than above)

If noted on examination, which ROM exhibited pain (select all that apply):

DorsiflexionPlantar flexion

Dorsiflexion degree endpoint (if different than above)


If noted on examination, which ROM exhibited pain (select all that apply):



If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe.

SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (continued)

RIGHT ANKLE LEFT ANKLE




degrees

Passive Range of Motion - Perform passive range of motion and provide the ROM values.

If noted on examination, which passive ROM exhibited pain (select all that apply):



Plantar flexion endpoint (45 degrees):


Passive Range of Motion - Perform passive range of motion and provide the ROM values.

If noted on examination, which passive ROM exhibited pain (select all that apply):

Same as active ROM

Same as active ROM

degrees

degrees

Same as active ROM

Same as active ROM







Is there evidence of pain? If yes, check all that apply.

Weight-bearing Nonweight-bearing

Causes functional loss (if checked describe in the comments box below)

Active motion Passive motion

Does not result in/cause functional loss

On rest/non-movement

Comments:

Is there evidence of pain? If yes, check all that apply.

Weight-bearing Nonweight-bearing

Causes functional loss (if checked describe in the comments box below)

Active motion Passive motion

Does not result in/cause functional loss

On rest/non-movement

Comments:

NoYes NoYes

NoYesIs there objective evidence of crepitus? NoYesIs there objective evidence of crepitus?

Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue?

NoYes

If yes, please explain. Include location, severity, and relationship to condition(s).

Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue?

NoYes

If yes, please explain. Include location, severity, and relationship to condition(s).


Is the Veteran able to perform repetitive-use testing with at least three repetitions?

Is there additional loss of function or range of motion after three repetitions?

If no, please explain:

If yes, please respond to the following after the completion of the three repetitions:

NoYes

NoYes

3B. Observed repetitive use ROM

Select factors that cause this functional loss. Check all that apply.

Incoordination

Lack of enduranceWeaknessFatigabilityPain

N/A



3B. Observed repetitive use ROM

Is the Veteran able to perform repetitive-use testing with at least three repetitions?

If no, please explain:

NoYes

Is there additional loss of function or range of motion after three repetitions?

NoYes



degrees

If yes, please respond to the following after the completion of the three repetitions:



degrees

Other:

Select factors that cause this functional loss. Check all that apply.

Incoordination


N/AOther:

Note: When pain is associated with movement, the examiner must give a statement on whether pain could significantly limit functional ability during flare-ups and/or after repeated use over time in terms of additional loss of range of motion. In the exam report, the examiner is requested to provide an estimate of decreased range of motion (in degrees) that reflect frequency, duration, and during flare-ups - even if not directly observed during a flare-up and/or after repeated use over time.

3C. Repeated use over time 3C. Repeated use over time

Is the Veteran being examined immediately after repeated use over time?

No Yes

Is the Veteran being examined immediately after repeated use over time?

No Yes

Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?

Yes No

Estimate range of motion in degrees for this joint immediately after repeated use over time based on information procured from relevant sources including the lay statements of the Veteran.

Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?

Yes No

Select factors that cause this functional loss. (Check all that apply)

Incoordination


N/AOther:


Incoordination


N/AOther:

Dorsiflexion endpoint (20 degrees): degrees


Estimate range of motion in degrees for this joint immediately after repeated use over time based on information procured from relevant sources including the lay statements of the Veteran.



The examiner should provide the estimated range of motion based on a review of all procurable information - to include the Veteran's statement on examination, case-specific evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. If, after evaluation of the procurable and assembled data, the examiner determines that it is not feasible to provide this estimate, the examiner should explain why an estimate cannot be provided. The explanation should not be based on an examiner's shortcomings or a general aversion to offering an estimate on issues not directly observed.


Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)




Is the examination being conducted during a flare-up?

3D. Flare-ups

NoYes

NoYes

LEFT ANKLERIGHT ANKLE

3D. Flare-ups

Is the examination being conducted during a flare-up?

NoYes

Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups?

Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups?

NoYes


Incoordination


N/AOther:


Incoordination


N/AOther:

Estimate range of motion in degrees for this joint during flare-ups based on information procured from relevant sources including the lay statements of the Veteran.



Estimate range of motion in degrees for this joint during flare-ups based on information procured from relevant sources including the lay statements of the Veteran.







Other, describe:

Interference with standing

Interference with sitting

Disturbance of locomotion

Instability of station

Atrophy of disuse

Deformity

Swelling

Weakened movement

More movement than normal Less movement than normal

None

In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:

Please describe additional contributing factors of disability:

3E. Additional factors contributing to disability 3E. Additional factors contributing to disability

In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:

Other, describe:

Interference with standing

Interference with sitting

Disturbance of locomotion

Instability of station

Atrophy of disuse

Deformity

Swelling

Weakened movement

More movement than normal Less movement than normal

None

Please describe additional contributing factors of disability:


SECTION IV - MUSCLE ATROPHY

4A. Does the Veteran have muscle atrophy?

4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section?

Yes No

Yes No

If no, provide rationale:

4A. Does the Veteran have muscle atrophy?

4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section?

Yes No

Yes No

If no, provide rationale:

LEFT ANKLERIGHT ANKLE

4C. For any muscle atrophy due to a diagnosis listed in Section I, indicate specific location of atrophy, providing measurements in centimeters of normal side and corresponding atrophied side, measured at maximum muscle bulk.

cmCircumference of atrophied side:

Circumference of more normal side: cm

Right lower extremity (specify location of measurement such as "1cm above or below ankle"):

4C. For any muscle atrophy due to a diagnosis listed in Section I, indicate specific location of atrophy, providing measurements in centimeters of normal side and corresponding atrophied side, measured at maximum muscle bulk.

Left lower extremity (specify location of measurement such as "1cm above or below ankle"):

cmCircumference of more normal side:

Circumference of atrophied side: cm

5A. Is there ankylosis of the ankle?

Dorsiflexion:

In good weight-bearing position

In poor weight-bearing position

With an eversion deformity

With an inversion deformity

With an abduction deformity

In dorsiflexion, between 0 degrees and 10 degrees

Plantar flexion:

In plantar flexion, less than 30 degrees

Note: Ankylosis is the immobilization of a joint due to disease, injury or surgical procedure.SECTION V- ANKYLOSIS

In dorsiflexion, between 0 degrees and 10 degrees

With an abduction deformity

With an inversion deformity

With an eversion deformity

In poor weight-bearing position

In good weight-bearing position

5B. Indicate angle of ankle ankylosis in degrees.

5A. Is there ankylosis of the ankle?

5B. Indicate angle of ankle ankylosis in degrees.

If yes, indicate the severity of ankle ankylosis: If yes, indicate the severity of ankle ankylosis:

Yes No Yes No

N/A no ankle ankylosis of joint N/A no ankle ankylosis of joint

Dorsiflexion:

Plantar flexion:

In plantar flexion, less than 30 degrees

In plantar flexion, between 30 degrees and 40 degrees In plantar flexion, between 30 degrees and 40 degrees

In plantar flexion at more than 40 degrees In plantar flexion at more than 40 degrees

In dorsiflexion at more than 10 degrees In dorsiflexion at more than 10 degrees

With an adduction deformity With an adduction deformity

5C. Is there ankylosis of the subastragalar or tarsal joint? 5C. Is there ankylosis of the subastragalar or tarsal joint?

Yes No Yes NoIf yes, indicate severity: If yes, indicate severity:


SECTION VI - JOINT STABILITY

Anterior Drawer Test: Is there absence of firm end point with asymmetric or excessive motion?

6A.Complete the following:

Talar Tilt Test: Is there asymmetric or excessive motion?

Unable to testNoYes

NoYes Yes No

Yes No Unable to test

6A Complete the following:

Anterior Drawer Test: Is there absence of firm end point with asymmetric or excessive motion?

Talar Tilt Test: Is there asymmetric or excessive motion?

SECTION VII - ADDITIONAL COMMENTS

If yes, indicate condition and complete the appropriate sections below:

7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?

Yes No

If yes, indicate condition and complete the appropriate sections below:

7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?

Yes No


Stress fracture of the lower leg (If this affects ROM of the knee, please complete the appropriate musculoskeletal questionnaire and ROM section)

Describe current symptoms:

"Shin Splints" (medial tibial stress syndrome - MTSS) "Shin Splints" (medial tibial stress syndrome - MTSS)

Stress fracture of the lower leg (If this affects ROM of the knee, please complete the appropriate musculoskeletal questionnaire and ROM section)


Responsive to surgery

Treatment for less than 12 consecutive months

Unresponsive to shoe orthotics or other conservative treatment

Requiring treatment for 12 consecutive months or more

Unresponsive to surgery

Indicate all treatment and symptoms below:

Responsive to surgery

Treatment for less than 12 consecutive months

Unresponsive to shoe orthotics or other conservative treatment

Requiring treatment for 12 consecutive months or more

Unresponsive to surgery

Indicate all treatment and symptoms below:


Achilles tendonitis or Achilles tendon rupture


Achilles tendonitis or Achilles tendon rupture

Indicate severity:

Moderate deformity

Marked deformity

Malunion of calcaneus (os calcis) or talus (astragalus)

Indicate severity:

Moderate deformity

Marked deformity

Malunion of calcaneus (os calcis) or talus (astragalus)

Unable to test Unable to test

If unable to test, please explain why: If unable to test, please explain why:

6B. If unable to test, is ankle instability suspected? Yes No

If yes, please describe:

6B. If unable to test, is ankle instability suspected? Yes No

If yes, please describe:


SECTION VII - ADDITIONAL COMMENTS (continued)LEFT ANKLERIGHT ANKLE

Talectomy


Talectomy


SECTION VIII - SURGICAL PROCEDURES

8A. Indicate any surgical procedures that the Veteran has had performed and provide the additional information as requested (check all that apply):

Total ankle joint replacement

Residuals:

None

Intermediate degrees of residual weakness, pain or limitation of motion

Chronic residuals consisting of severe painful motion or weakness

Other, describe:

Date of surgery:Date of surgery:

Other, describe:

Chronic residuals consisting of severe painful motion or weakness

Intermediate degrees of residual weakness, pain or limitation of motion

None

Residuals:

Total ankle joint replacement

8A. Indicate any surgical procedures that the Veteran has had performed and provide the additional information as requested (check all that apply):

No surgeryNo surgery

Describe residuals:

Residuals of arthroscopic or other ankle surgery

Arthroscopic or other ankle surgery

Type of surgery:

Date of surgery:Date of surgery:

Type of surgery:

Arthroscopic or other ankle surgery

Residuals of arthroscopic or other ankle surgery

Describe residuals:

No

Yes (If yes, complete the Knee and Lower Leg Conditions questionnaire)

Does this condition affect ROM of knee?

No

Yes (If yes, complete the Knee and Lower Leg Conditions questionnaire)

Does this condition affect ROM of knee?

Describe current symptoms: Describe current symptoms:


9B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section?

Yes No

If yes, complete appropriate dermatological questionnaire.

10A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?

Crutches

Walker Frequency of use: Occasional Regular Constant

ConstantRegularOccasionalFrequency of use:Cane

Frequency of use: Occasional Regular Constant

Wheelchair Frequency of use: Occasional Regular Constant

Frequency of use: Occasional Regular Constant

Yes No

If yes, identify assistive devices used (check all that apply and indicate frequency):

SECTION X - ASSISTIVE DEVICES

Other:

ConstantRegularOccasionalFrequency of use:Brace(s)

10B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.

11A. Due to the Veterans ankle condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis (functions of the lower extremity include balance and propulsion, etc.)?

SECTION XI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

No

Right lower

11B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

Left lowerIf yes, indicate extremities for which this applies:

Yes, functioning is so diminished that amputation with prothesis would equally serve the Veteran.

Note: The intention of this section is to permit the examiner to quantify the level of remaining function; it is not intended to inquire whether the Veteran should undergo an amputation with fitting of a prosthesis. For example, if the functions of grasping (hand) or propulsion (foot) are as limited as if the Veteran had an amputation and prosthesis, the examiner should check "yes" and describe the diminished functioning. The question simply asks whether the functional loss is to the same degree as if there were an amputation of the affected limb.

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS

9A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above?

NoYes

If yes, describe (brief summary):


12A. Have imaging studies been performed in conjunction with this examination?

Note: Testing listed below is not indicated for every condition. The diagnosis of degenerative arthritis (osteoarthritis) or post-traumatic arthritis must be confirmed by imaging studies. Once such arthritis has been documented, even if in the past, no further imaging studies are required by VA, even if arthritis has worsened.

SECTION XII - DIAGNOSTIC TESTING

Yes

12B. If yes, is degenerative or post-traumatic arthritis documented?

Indicate side: Right BothLeft

No

Yes No

12C. If yes, provide type of test or procedure, date and results (brief summary):

12D. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination?

If yes, provide type of test or procedure, date and results (brief summary):

Yes No

12E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:


14A. Remarks (if any – please identify the section to which the remark pertains when appropriate).

SECTION XIV - REMARKS

13A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?

SECTION XIII - FUNCTIONAL IMPACT

No

If yes, describe the functional impact of each condition, providing one or more examples:

Yes

Note: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.

SECTION XV - EXAMINER'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

15A. Examiner's signature: 15B. Examiner's printed name and title (e.g. MD, DO, DDS, DMD, Ph.D, Psy.D, NP, PA-C):

15E. Examiner's phone/fax numbers: 15F. National Provider Identifier (NPI) number: 15G. Medical license number and state:

15H. Examiner's address:

15C. Examiner's Area of Practice/Specialty (e.g. Cardiology, Orthopedics, Psychology/Psychiatry, General Practice): 15D. Date Signed:

ANKLE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE …

Documents

Transcript of ANKLE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE …